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Full text of "United States Navy Medical News Letter Vol. 43 No. 7, 3 April 1964"

NavMed P-369 







Vol. 43 



Friday, 3 April 1964 



No. 7 



TABJLE OF CONTENTS 



MEDICAL, ABSTRACTS 



DENTAL SECTION (Cont'd) 



Non- Traumatic Urologic 

Emergencies 3 

Management of Urinary Tract 

Injuries 7 

Gallstones in Yoimg Adults 9 

Therapy of Schizophrenia - A 

Major Joint Study Report 13 

Radiation Medicine: 

Attention - AH AEC Licensed 

Naval Hospitals 15 

MISCELLANY 

Notice of Drug Withdrawal 17 

Important Drug Warnings 18 

FROM THE NOTE BOOK 

Meeting of the American College 

of Physicians 19 

Wanted: Articles for Training 

Bulletin 20 

MSC Training Announcement .... 20 
A. P. A. To Hold Navy LTincheon. . 21 
BUPERS REPORT 1080-14 21 



Incidence and Distribution of 

Dental Caries in the U. S 23 

Improved Dental Cements 23 

Fluoride Useful in Combating 

Bone Diseases 24 

AMA Position on Fluoridation .... 24 
Professional Notes 25 

PREVENTIVE MEDICINE 

Measles Epidemic in the 

Bonin Islands 27 

Mianeh Fever 28 

Control of Gonococcal Infection ... 28 
Time-Temperature Effects 

on Salnnonellae and 

Staphylococci in Food 31 

Epidemiology of Salmonellosis. ... 31 

Know Your World 34 

Research Projects Completed 

by Preventive Medicine Unit 

No. 2 . 35 

Malaria Eradication in 1962 36 

RESERVE SECTION 



DENTAL SECTION 

Incisal Guidance in Oral 
Rehabilitation 



22 



Attention: Reserve Nurse Corps 

Officers on Inactive Duty 39 

Reservists Eligible for Tax 

Deductions 39 



United States Navy 
MEDICAL NEWS LETTER 



VoL 43 Friday, 3 April 1964 No. 7 

Rear Admiral Edward C. Kenney MC USN 
Surgeon General 
Rear Admiral A. S. Chrisman MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain K. W. Schenck MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter to: Commanding Officer, 
U.S. Naval Medical School, National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new addresses. 



The issuance of this publication approved by the Secretary of the Navy on 
28 June 1961. 



Medical News Letter, Vol. 43, No. 7 



Non-Trauimatic Urologic Emergencies 

LT W. P. Urschel MC USN *. Proceedings of the Monthly Staff 
Conferences of the U. S. Naval Hospital, NNMC, Bethesda, Md. , 
1962 - 1963. 

The definition of "emergency, " according to Webster, is a "sudden or unex- 
pected occurrence. " In Urology, this may mean something should be done 
withinan hour's time as with torsion of the testis or with gross hematuria; or it 
may m.ean the proper time for intervention should be within 24 to 72 hours, 
as in the case of some calculi and some traumatic injuries. 

I. Gross Hematuria 

Hematuria is a danger signal which cannot be ignored. It is important to know 
whether urination is painful, whether there are associated signs of bladder 
irritability, and whether blood is seen in all, or in only part, of the urinary 
stream. Initial hematuria suggests an anterior urethral lesion; terminal 
hematuria usually comes from the posterior urethra, bladder neck, or tri- 
gone; and total hematuria indicates bleeding from the bladder or upper tracts. 
Hematuria associated with renal colic suggests ureteral stone, although a 
clot from a bleeding renal tumor can cause the same type of pain. Nonspecific 
or tuberculous infection is frequently associated with hematuria, A stone in 
the bladder may cause hematuria, but usually there are associated infection 
and symptoms of bladder neck obstruction or cystocele. When a tumor of the 
bladder ulcerates, it is often complicated by infection and bleeding and, thus, 
symptoms of cystitis and hematuria are also compatible with neoplasm. 

Gross total painless hematuria must be regarded as a symptom of 
tumor of the bladder or the kidney until proved otherwise, and this constitutes 
a real urologic emergency. Cystoscopy is indicated at once since this type 
of hematuria is often intermittent and may not recur for months. Statistically, 
there is more than a 90% chance of finding the source of the bleeding if the 
patient can be attended while this is still occurring. Complacency, because 
the bleeding stops, should be condemned. This department cannot suggest too 
strongly the immediate referral of all patients seen with gross total painless, 
hematuria. 

II. Testicular Tumors 

A mass which cannot be definitely differentiated from the testis must be 
regarded as a tumor until proved otherwise. Because of the poor prognosis 
of testicular tumors and because their maxinnum incidence occurs in the 
20 to 35-year age group, conservative treatment in cases of a testicular mass 
consists of immediate surgery through an inguinal incision where the blood 
supply from the testis can be controlled and the testis can be examined by 



* Resident in Urology at the Hospital 



4 Medical News Letter, Vol. 43, No. 7 

direct vision. A review of the literature reveals some differences in survival 
statistics but, in general, it is as follows: seminoma - 90 to 95% five-year 
survival rate; teratoma - 60 to 70% five-year survival rate. 

Patients with embryonal carcinoma have a 30 to 40% five-year survival 
and patients with the most deadly choriocarcinoma have only a 5 to 10% chance 
of living two years. 

Clinically, testicular tumors are usually painless, although some 40% 
of patients have noted moderate discomfort at some time. These tumors vary 
from small nodules of the size of a pea to 5-pound diffuse enlargements of the 
testis. The patient's attention is usually directed to these nodules after some 
trauma so that history of present illness is somewhat unreliable. There are 
no early symptoms except increase in size and hardness of the testis which, 
if the tumor is not first noted by symptoms of metastasis, may cause a dull 
ache in the lower abdomen or groin due to a drag on the spermatic cord. This 
is often dismissed as a "strain, " since elevation produces relief. Many of 
these tumors nnetastasize to the para-aortic nodes before a primary lesion 
is found. Any young male with a dull ache in the lumbar area or groin and who 
considers it important enough to mention tb a doctor should have a thorough 
examination of the scrotal contents » 

Differential diagnosis includes the following: 

A hydrocele may be quite tense and firm, but usually will permit transillum- 
ination. It should be remembered, however, that 10 to 15% of testicular tumors, 
particularly the slower -growing varieties, will also have some degree of hy- 
drocele which can be trans illuminated. 

A spermatocele is a free cystic mass lying above and behind the 
testis and, in most cases, presents no problem. 

Epididymitis, where acute, is exceedingly painful and is usually accom- 
panied by some abnormal urinary findings. If seen in the early stages, it can 
easily be differentiated from the testis itself. Chronic epididymitis and tuber- 
culous epididymitis present somewhat more of a problem but should, on care- 
ful examination, be separable from the testis. 

A gumma is a rare nontender testicular lesion which causes enlarge- 
ment; a history of syphilis and a positive serologic test suggest the diagnosis. 

Mumps orchitis is usually much more painful than a tumor and almost 
always is accompanied by parotitis. 

Torsion of the spermatic cord (discussed in detail below) is an emer- 
gency of adolescence. Often, in addition to being more painful the epididy- 
mis can be felt anterior to the testis. In addition, elevation of the testis 
increases the torsion and pain. 

It is imperative that early diagnosis of testicular tumors be made. 
An. average period of three months elapses from the first symptoms to the 
time when the patient sees a doctor, but recognition of the tumor by the doc- 
tor generally will take six to nine months. In Campbell's series of more 
than 4000 cases, 88% had demonstrable metastases by the time surgery was 
performed. At this installation, any intra-scrotal swelling which cannot be 



Medical News Letter, Vol. 43, No. 7 5 

definitely identified or separated from the testis is treated as an emergency, 
and surgery is performed within 24 hours. 

III. Ureteral Colic 

This is one topic with which most physicians are quite familiar, and concerning 
which the general surgical residents and Ob/Gyn residents are all familiar. 
Clinically, pain from calculi is usually abrupt in onset, and becom,es severe 
within a matter of minutes. There are two types of pain: (1) radiating colicky 
agonizing pain from hyperperistalsis of the smooth muscle, and (2) the some- 
what constant ache in the costovertebral area and flank from obstruction and 
capsular tension. The radiation of the pain, at times, suggests the position 
of the stone. If it is high in the ureter, the colic may radiate to the testicle. 
As the stone migrates toward the bladder, the pain may spread to the scrotum 
or the vulva. At times, the pain comes on more slowly and may be felt 
anteriorly. Occasionally, it may be quite mild. Gastrointestinal symptoms 
are usually associated with ureteral stones; nauseaand vomiting almost always 
occur. Abdominal distention due to paralytic ileus is usually present. Hema- 
turia is seen grossly in one-third of cases, and hematuria, microscopically, 
in almost every case. 

Even in the absence of infections, symptoms of urgency and frequency 
may develop as the stone approaches the bladder. Existing chronic renal 
infection may be exacerbated by ureteral obstruction; chills, fever, and upper 
back pain may be noted. The patient is usually in agony, pacing the floor 
rather than lying quietly in bed (as a patient with peritoneal irritation is apt 
to do). Nothing he does gives him relief. His skin may be cold and clamtmy 
and he may show signs of mild shock. 

Other urologic causes of ureteral colic include: 

Passage of crystals down the ureter may occur during an exacerbation of gout 
or in oxaluria with excessive ingestion of high oxalate foods. Signs and symp- 
toms are the same as with stone, and hematuria is just as common. X-Ray 
findings are usually negative, however, and the presence of many crystals in 
the urine may suggest the etiology of the colic. 

A tumor of the kidney or renal pelvis may bleed, and a clot or piece 
of necrotic tumor tissue may pass down the ureter. This will siraulate per- 
fectly a ureteral stone. Excretory urograms would be expected to show a 
space-occupying lesion in the kidney and, often, a "negative shadow" in the 
ureter. A ureteral tumor is often partially obstructive and may cause colic. 
Hematuria is common. 

Acute pyelonephritis may start so abruptly and the pain may be so 
acute as to suggest the presence of a stone. The finding of pyuria and 
bacteriuria with normal urograms should establish the diagnosis. 

The nonurologic entities often confused with ureteral colic; 

An attack of colic on the right side nnust be differentiated from biliary colic 
or acute appendicitis, and symptoms from a lower left ureteral stone from 



6 Medical News Letter, Vol. 43, No. 7 

diverticulitis. Symptoms simulating acute intestinal obstruction or other 
acute intraperitoneal catastrophies may be produced by an attack of colic 
located on either side. Biliary colic may be differentiated by history of pres- 
ent illness and the absence of tenderness in the right renal area. The pain 
in gallbladder colic is usually manifested in the back or right shoulder. Local 
examination reveals tenderness over the gallbladder with rectus muscle 
spasm. Microscopically, the urine rarely shows red cells. 

Acute appendicitis, at times, may be more difficult to differentiate 
from a ureteral calculus. Again, significant data are elicited from the history. 
In acute appendicitis, the point of maximum tenderness is usually localized 
to the right lower quadrant, with muscular spasnn, rigidity, and rebound ten- 
derness frequently present. Tenderness is usually absent over the kidney and 
the general constitutional symptoms may be more pronounced. The pulse is 
rapid and the temperature tends to be higher. The white count is most often 
higher than with a ureteral stone unless prior urinary tract infection is pres- 
ent. There are routinely no red cells seen in the urine in appendicitis, but 
this rule, unfortunately, often is broken. 

In the presence of general abdominal distention, failure to pass gas 
per rectum, and vomiting, one may suspect intestinal obstruction. 

In women, differentiating ureteral colic (when the stone is low) from 
an acute ovarian problem may be difficult. In many cases, on bimanual recto- 
vaginal examination, a calculus actually may be palpated and the problein 
resolved. 

IV. Torsion of the Testis 

The fourth and last emergency discussed in this article is torsion of the 
spermatic cord or the testis. This is a rotational strangulation of the blood 
supply to the testis which, if not treated quickly, (within an hour or less) will 
result in testicular atrophy or in gangrene. This is not a common problem, 
but a fast accurate diagnosis is imperative, and the physician's index of 
suspicion is all -important. Generally, this is considered to be a problem of 
boys near the age of puberty, but this may be due to mistaken diagnoses of 
acute epididymitis later in life. The undescended testis is prone to undergo 
torsion, and half of the torsion cases are those of undescended testes. 

Clinically, one should consider the diagnosis when a young patient 
suddenly develops severe pain in one testis, reddening and swelling of the 
scrotal skin, lower abdominal pain, and nausea and vomiting. Examination 
reveals a swollen tender testis which is usually retracted upwards, and if 
felt in the early stages, has the epididymis anterior to the testis. The dif- 
ferential diagnosis includes acute epididymitis, acute orchitis, trauma, 
strangulated hernia, and torsion of the appendix testis. 

Acute epididymitis is rare in the pre-pubertal group. There are uri- 
nary findings which often will be relieved by elevation of the testes. In tor- 
sion, elevation of the testis almost always exacerbates the pain. 

Mumps orchitis is usually associated with parotitis and rarely occurs 
before puberty. 



Medical News Letter, Vol. 43, No. 7 7 

A strangulated hernia, particularly in cryptorchidism, is difficult to 
distinguish from torsion; surgery is indicated without delay. 

Torsion of the appendix testis (hydatid of Morgagni) may manifest 
symptoms identical to a torsion of the testis and, again, surgery is indicated. 

Occasionally, manual detorsion can be accomplished by the adminis- 
tration of a sedative and by genUe rotation, but because of the certainty of 
losing the testis unless the strangulation is relieved, this manipulation should 
not be protracted. 

It is generally agreed that bilateral orchiopexies are indicated if 
torsion is found. 

• ***** * . , . . . 

Management of Urinany Trac t Injuries • :, , 

L,T R. E. Akers MC USN*. Proceedings of the Monthly Staff <,;.., 

Conferences of the U. S. Naval Hospital, NNMC, Bethesda, Md. , 
1962 - 1963. 

Injuries to the kidneys, urinary bladder, or urethra are not infrequently 
encountered in emergency room practice, and are often concomitant with 
injuries elsewhere in the body. Hematuria or inability to micturate, asso- 
ciated with a history of trauma, should immediately arouse suspicion of 
urinary tract damage. Most of the urinary tract is located in well-protected 
areas of the body and, therefore, is not injured as frequently as are the more 
vulnerable organs. When urinary tract trauma does occur, injuries to the 
spine, chest, pelvis, and intra-abdominal organs, such as the liver and the 
spleen, should be ruled out. 

Kidney injuries are broadly classified as those which are due either 
to penetrating or nonpenetrating trauma. Penetrating wounds which involve 
the kidney are all treated surgically and are not included in this discussion. 
Nonpenetrating renal injuries may be divided into three groups according to 
severity. 

Group I injuries, variously termed contusions or intracapsular injuries, 
involve only the renal parenchyma, and do not involve the capsule or collect- 
ing system of the kidney. This type of injury is characterized clinically by 
evidence of varying amounts of gross or microscopic hematuria, and usually 
moderate pain and tenderness in the renal area. Gross hematuria ordinarily 
does not persist for more thajQ 12 to 24 hours. Excretory urograms are most 
often normal, but may show filling defects in the collecting system because. of 
the presence of blood clots. 

Group II or moderately severe injuries include those which extend be- 
yond the renal capsule and/or involve the collecting system. Pain and ten- 
derness are usually more severe and hematuria more marked, although the 



* Senior Resident in Urology at the hospital, Doctor Akers has been selected 
for promotion to the rank of Lieutenant Commander. 



8 Medical News Letter, Vol. 43, No. 7 

last symptom is sometimes less pronounced because of ureteral obstructions, 
secondary to blood clots. A palpable flank mass, localized abdominal rigidity, 
and discoloration of the overlying skin may be encountered; shock is often 
present. Excretory urograms will usually reveal nonfunction of the injured 
kidney and presence of a retroperitoneal mass. 

Patients suspected of having received renal injury should be assessed 
immediately. A hematocrit, complete blood count, and urinalysis should be 
obtained, in addition to a complete history and thorough physical examination. 
Patients who are unable to void should be catheterized, and a Foley catheter 
should be left indwelling if considerable gross hematuria is present. Shock, 
when present, should be treated immediately. Excretory urograms, the most 
important single test, should be done as soon as possible. This will not only 
help to assess the damaged kidney, but will give valuable information regard- 
ing the condition of the uninjured kidney. Cystoscopy should be performed and 
retrograde pyelograms made when necessary for diagnosis. Antibiotic therapy 
should be instituted, and the patient's condition evaluated frequently by means 
of physical examination, hematocrits, blood counts, and assessment of 
hematuria. 

Group I injuries are treated conservatively by bed rest, antibiotics, 
and good hydration. Bed rest should be continued until all microscopic hema- 
turia has cleared. 

Group II injuries, if not too severe and when not complicated by other 
abdominal injuries, may also be managed initially by conservative treatment. 
Surgical intervention, however, may be necessary at any time in this group. 
It is indicated by occurrence of intractible shock or hemorrhage, a rapidly 
expanding flank mass, overwhelming sepsis, and extracapsular extravasation 
of urine. Many urologists advise that surgery be delayed, when possible, for 
48 to 72 hours, thereby allowing a clearer delineation of the extent of the 
damage. This is particularly applicable when the uninjured kidney is diseased 
and, therefore, salvage of the injured kidney is extremely desirable. 

Group III , severe injuries, are all treated surgically, usually by 
nephrectomy. Ureteral injuries are mostly due to surgical accidents and are 
not discussed in this article. 

Urinary bladder injuries commonly occur as a consequence of auto- 
mobile accidents, but may result from a single fall, particularly in the case 
of an intoxicated patient and when the bladder is full. Spontaneous rupture 
of the bladder may occur in inebriates with over -distention from prostatism. 

Ruptures of the bladder are usually classified as intraperitoneal or 
extraperitoneal; however, both types can occur concurrently. Injury to the 
bladder should be suspected when there is a pelvic fracture or when lower 
abdominal trauma is associated with gross hematuria and/or the inability to 
void. Abdominal pain and tenderness are usually present, and shock is a 
common companion, particularly with intra-abdominal extravasation of urine. 
A cystogram will reveal extravasation of contrast agent. 

All patients suspected of having a ruptured bladder or who have a pel- 
vic fracture should be catheterized and a cystogram obtained. It is important 



Medical News Letter, Vol. 43, No. 7 9 

to obtain films of the bladder when both filled and post -drainage, as well as 
oblique views when possible. Many low extraperitoneal ruptures may not be 
diagnosed by a single X-Ray film when the bladder is filled. Treatment con- 
sists of immediate surgical repair, adequate drainage of extravasated urine, 
and antibiotics. 

Injuries to the male urethra occur most commonly from automobile 
accidents, and from "straddle" type injuries. Urethral damage should be 
suspected when there isahistory of trauma accompanied by hematuria, and/or 
inability to void. These injuries are classified according to locations— anter- 
ior or posterior— the divisions being the urogenital diaphragm. When urethral 
injury is suspected, catheterization should be attempted; if successful, the 
catheter should be left indwelling. The catheter will often meet obstruction 
at the point of rupture. If a catheter cannot.be introduced, a urethrogram 
should be obtained. 

Physical findings may include lower abdominal fullness and tender- 
ness, an anterior rectal mass and, occasionally, a "floating" prostate when 
there is a complete rupture at the urogenital diaphragm. With anterior ure- 
thral injuries, there may be swelling and discoloration of the lower abdomen, 
penis, scrotum, and perineum secondary to extravasation of urine. Treat- 
ment of urethral ruptures consists of: diversion of urine proximal to the point 
of injury, drainage of extravasated urine, repair of rupture, and antibiotics. 

s;; sjc :{( ^ ;{; :{! 

Gallstones in Young Adults 

An Analysis of 178 Patients Under Thirty Years of Age 

LCDR Richard G. Fosburg * MC USN, Philadelphia, Pennsylvania.** 
Amer J Surg 106(1): 82-88, July 1963. 

The frequency of gallstones in young adults continues to be unappreciated. As 
late as 1959, reports have appeared emphasizing the unusual nature of chole- 
lithiasis in the second and third decades of life. The concept of gallstones as 
a disease in patients over 40 years of age persists despite the fact that from 
4 to 20% of reported series of cholecystectomies are in patients under 30 
years of age. A review of the English literature reveals few studies of sig- 
nificant size which deal specifically with cholelithiasis in young adults. If 
improvennent is to continue in the reduction of the morbidity and mortality 
associated with cholelithiasis, earlier diagnosis is essential. 

In an attempt to elucidate certain factors which nnight aid in the earlier 
diagnosis of these patients, an analysis was made between 178 patients under 
30 years of age with 404 patients over 30 years. Several reported series of 

* Present address: USS INDEPENDENCE c/o Fleet Post Office, N. Y. , N. Y. 
** From the Department of Surgery, United States Naval Hospital, Philadel- 
phia, Penna. 



10 



Medical News Letter, Vol. 43, No. 7 



cholecystectoinies were also reviewed and the findings correlated with those 
of this study. Results of this analysis constitute the basis of this report. 

CLINICAL DATA 



Table i 

in 68 1 total admissions for disease of the 

biliary tract 582 patients fulfilled 

the criteria selected for study 



Under Thirty Years of Age, 1 78 



Over Thirty Years of Age, 404 



Operative, 150 


Medical, 28 


Operative, 335 


Medical, 69 


Men 


Women 


Mea 


Women 


Men 


Women 


Men 


Women 


25 


... 


2 


z6 


154 


181 


S3 


16 



All patients admitted for disease of the 
biliary tract to the U. S. Naval Hospital, 
Philadelphia, Penna. , during the 6 -year 
period, January 1955 to January 1961, 
were reviewed. Only those patients in 
whom roentgenograms revealed evidence 
of gallbladder disease or in whom patho- 
logic examination after operation proved 
the existence of cholelithiasis were se- 
lected for study. For the purpose of com- 
parison, patients under 30 years of age 
were arbitrarily classified as young adults. Of the 681 admissions reviewed, 
582 fulfilled the criteria selected for study; of these, 178 (30. 6%) were under 
30 years. 

That more patients have been encountered in the younger age groups 
than generally seen in the average hospital practice is a reflection of the 
nature of the population presenting to a large military hospital. Many of the 
female patients cared for are dependents of young adults in the Armed Forces 
and are seen during the childbearing age. The male population, despite initial 
screening and induction requirements, represents a greater concentration of 
young men than would be encountered in a civilian community. Because of the 
bias introduced by this preselection, the reported results from several other 
large hospitals have been utilized in the comparisons that follow. 

Table I summarizes the breakdown of clinical material. There were 
485 patients treated surgically and 97 patients treated medically. Of the 485 
patients who underwent operation, 150 (30. 9%) were under 30 years of age. 
The 28 medical patients under 30 years were encountered during the last year 
of the study, and the majority have subsequently undergone operation. 

CLINICAL ANALYSIS 

Age and Sex . There were 234 men and 348 women in the entire series, 
a ratio of 1:1. 5. In the group under 30 years of age, there were 27 men and 
151 women, a ratio of 1:5.6. In the decade 10 to 19 years, there were 3 men 
and 33 women; in the decade 20 to 29 years, there were 24 men and 1 18 women. 
The youngest man was 18 and the youngest girl 15 years of age. The oldest 
man was 81 and the oldest woman was 85 years of age. 

Acute Versus Chronic Cholecystitis . Of the 582 cases, 159 (27. 3%) 
patients presented with acute cholecystitis and 423 (72. 7%) entered the hos- 
pical with the diagnosis of chronic cholecystitis or some unrelated diagnosis. 
Acute cholecystitis was the presenting illness in 42% of patients under 30. 
In the decade, 10 to 19 years, 29 of 36 patients (80%) presented with acute 
cholecystitis. In the decade, 20 to 29 years, 45 of 142 patients (31.7%) 



Medical News Letter, Vol. 43, No. 7 11 

presented with acute cholecystitis. In the subsequent three decades, fewer 
than 20% of patients presented with acute cholecystitis; however, the incidence 
increased markedly in the elderly. The increased incidence of severe attacks 
of acute cholecystitis in the younger patients stands in marked contrast to the 
total series. The reported incidence of acute cholecystitis in other series 
varies from 5 to 20%. 

Pain. The most common symptom encountered was epigastric pain 
or pain in the right upper quadrant. Eighty-six percent of all patients exper- 
ienced pain in the right upper quadrant some time during their hospitalization, 
although it was the presenting complaint in only 67%. Radiation of pain to the 
back, scapula, or shoulder top was noted in 19% of patients, but was present 
more frequently in the younger group, 32% versus 13%. In the younger group 
of patients, the pain was surprisingly different when compared to the older 
patients. The pain was limited to the epigastrium in 48% of the young adults. 

Miscellaneous . Fatty food intolerance or a history of attacks in re- 
lation to meals was encountered in 40% of patients. In only 20% of the young 
adults could such a history be elicited. As the age of the patient increased, 
this complaint was noted more frequently and was present in 70% of patients 
60 years of age or over. In many older patients this may well reflect a gen- 
eral dietary intolerance. The absence of this complaint, however, was re- 
sponsible for the initial exclusion of biliary tract disease in many patients. 

Complaints of dyspepsia, eructation, and flatulence were rare in the 
younger group, being noted in only 12%. 

Jaundice . In the entire series, 63 patients (10.8%) had jaundice at the 
tim,e of admission. This compares favorably with the incidence reported in 
the literature. In patients with acute cholecystitis and jaundice, there was 
little difference between the two age groups. Of the 42 patients with acute 
cholecystitis with jaundice in the entire series (26. 4%) of all patients with 
acute cholecystitis) there were 22 patients (29. 7%) in the age group under 30 
years and 20 patients (23. 5%) over 30. No patients under 30 years presented 
with chronic cholecystitis and jaundice; however, 21 patients (6. 6%) of those 
over 30, with chronic cholecystitis, had jaundice. 

Associated Disease . The attempts to associate other diseases in a 
causal relationship to cholelithiasis have proved uniformly unsuccessful. 
Many observers have noted a relatively high incidence of gallstones in dia- 
betics. Diabetes mellitus was encountered in only one patient under 30 years 
of age (0. 5%) as compared to 8. 4% of patients over 30, 

The incidence of peptic ulcer disease in those under 30 was 3. 3% and 
5. 3% in those over 30 years of age. There is no evidence that peptic ulcer 
disease affects the incidence of cholelithiasis. The discovery of multiple 
diseases of the gastrointestinal tract is related to the diagnostic studies per- 
formed as part of the evaluation of such patients. The association of chole- 
lithiasis, diverticulosis, and hiatus hernia was not encountered in those under 
30, but was seen in 9% of those over 30 years. However, this triad was not 
looked for in every patient and the actual incidence might be considerably 
higher. 



12 



Medical News Letter, Vol. 43, No. 7 



Any attempt to correlate obesity with gallstones is fraught with hazard 
since it is impossible to determine the weight of the patient at the time gall- 
stones form as compared to the time when they beconne symptomatic. For 
completeness, however, 13. 3% of patients under 30 were obese { 10% above 
standard weight) as contrasted to 30. 9% of those over 30 years. 

Operative Data . Of the 485 patients undergoing cholecystectomy, 
150 {30. 9%) were under 30 years of age. Of those operated upon for acute cho- 
lecystitis, 28 (18. 7%) were under 30 years and 43 (12. 8%) were over 30. No 
deaths occurred In the younger group. The operative mortality in those over 
30 was 2. 7% and the mortality for the entire series was 1. 8%. 

The common duct was explored in 29 patients (19. 3%) under 30 and in 
98 (29.2%) in those over 30. Of those explored, stones were found in the 
common duct in 6 (20. 7%) of patients under 30 and in 46 (46. 9%) of those over 
30. All 63 patients who had jaundice during their hospitalization had common 
duct exploration. Acute cholecystitis with jaundice was seen in 42 patients 
and 17 (40. 5%) were found to have common duct stones. In the group under 
30 years of age, 6 of 22 patients (27. 3%) had common duct stones; In those 
over 30 years, 11 of 20 patients (55%) had common duct stones. The 21 pa- 
tients with chronic cholecystitis and jaundice all had common duct stones; 
none were under 30 years of age. Fourteen patients (4. 2%) in the group over 
30 years old had corpmon duct stones without clinical jaundice. The incidence 
of common duct stones in the total series was 10. 7%. 



Table ii 

FREQUENCY OF GALLSTONES IN PATIENTS UNDER THIRTY YEARS OF AGE 



Author 



Blalock 

Eliason 

Bearse and Fergeson 

Biskind and PevarofF 

Smith 

Adams and Stranahan 

Dunphy and Ross 

Gaster 

Griffin and Smitfi 

Cokock and McManus 

Becker, Powell and Turner 

Sparkman 

Johnson and Close .^ 

McEachern and Sullivan 

Byrne 

Smith 

Pearce 

Pearce 

Sethi 

Weckesser 

Fosburg 

Total 

* Includes patients thirty years of age 



Year 



1924 
1927 
1941 
1942 
1945 
1947 
1949 
1950 
1954 
1955 
1957 
1957 
1957 
1959 
1959 

1959 
i960 
i960 
1961 
1 961 
1962 



Total 



724 
128 
232 
746 
332 
II 04 

134 
533 
245 
1356 
1060 
100 
103 
155 
134 
148 
172 

395 

274 

3085 

485 



11645 



Under 

Twenty 

Years 

of Age 



II 
I 



8 

3 

J9 

I 
3 



28 

33 



117 



Per cent 



Under 
Thirty 
Years 
of Age 



100 

13 
48 

no* 
21 
76* 
II 
24 
35* 
74* 

142* 
23* 
17 
17 
6 
21 

9 
28 

38 
276 
150 



1239 



Per cent 



13-8 

lO.I 

20.6 

14.7 

6.3 

6.9 

8.2 

4 5 

14.4 

5-4 
13.4 

23 

16. 

10. 

4- 
14. 

5- 
7-1 
5.8 
8.9 
30 9 



10.6 



Acute 

or 
Chronic 



A/C 
A/C 
A/C 
A/C 

A 
A/C 

A 
A/C 
A/C 
A/C 

A 
A/C 

A 

A 

A 
A/C 

A 

C 

A 
A/C 
A/C 



A/C 



Medical News Letter, Vol. 43, No. 7 



13 



Table hi 
differences elucidated in this analysis 



Disease 



Under 
Thirty 
Years of 

Age 
(Per cent) 



Acute cholecystitis 

Operated on for acute chole- 
cystitis 

Chronic cholecystitis 

Pain limited to epigastrium . . . 

Radiation of pain 

Radiation of pain to back 

Radiation to shoulder top 

Nocturnal attacks 

Fatty food intolerance 

Dyspesia, eructation and 
flatulence 

Acute cholecystitis with jaun- 
dice due to common duct 
Stone 

Stones in common duct 

Common duct explored 

Retained common duct stones. 

Operative mortahty 

Postoperative morbidity rate 



Over 

Thirty 

Years of 

Age 
(Per cent) 



A total of thirty-one different post- 
operative complications were seen in 
the entire group for a morbidity rate 
of 18.2%. Complications were en- 
countered in 12 of 150 patients under 
30 years of age for a morbidity rate 
of 8% as contrasted to 76 of 335 pa- 
tients over 30 (22.6%). Of these com- 
plications, wound infection was the 
most common followed by atelectasis 
and pneunnonia. Retained common duct 
stones occurred in 3 patients, all over 
30 years of age, an incidence of 0. 6% 
in the total series. 

These results are similar to those 
of others and warrant no special com- 
ment except to emphasize that a grati- 
fyingly low morbidity and no mortality 
is possible in young adults under the 
age of 30 years. 

Comments . The frequency of gall-^ 
stones in patients under 30 years of age has been sunnmarizedin Table II from 
several collected series of cholecystectomies in which the age was specifically 
stated. Table III summarizes the differences elucidated in this analysis. It has 
been a well documented fact that the incidence of gallstones increases with age. 
The majority of studies dealing with biliary tract disease have found the great- 
est incidence in the fifth or sixth decade. This finding has been substantiated 
by both clinical and autopsy analyses. 

NOTE: Interested persons are urged to read the original article which con- 
tains forty-two references and an excellent comparative review of the 
related literature by Doctor Fosburg. — The Editor 



21 .0 
12.8 

79.0 

lO.O 

13,0 

27.0 
16.0 

17.0 

60.0 
60.0 



55.0 
46.9 

29.2 
0.6 

2-7 
22.6 



* =5: * 



* * 



Therapy of Schizophrenia - A Major Joint Study Report 



New evidence of marked efficacy of drugs in treatment of schizophrenia was 
released by the Public Health Service and collaborating scientists on 6 March 
1964. A comprehensive study, supported and directed by the National Institute 
of Mental Health in Bethesda, Md. , shows that 95% of schizophrenics treated 
by drugs improved within 6 weeks; 75% showed marked to moderate improve- 
ment, according to results of the two and a half year study reported in a recent 
issue of Archives of General Psychiatry . 

This is the first large-scale study in which acutely ill patients were 
treated in varying types of psychiatric hospitals. They ranged from small 



14 Medical News Letter. Vol. 43, No. 7 

private hospitals to large State institutions. The Institute's Psychopharma- 
cology Service Center enlisted nine hospitals to make up the Collaborative 
Study Group. Earlier studies have been limited to hospitals of a single type. 
These results, coupled with findings from other research by the Institute 
suggest that these drugs will be highly effective tools for treating schizo- 
phrenics in comprehensive community mental health centers where the em- 
phasis is on rapid and early treatment near the patient's home. The hope is 
that many of these patients can thus avoid tragic years in institutions. The 
investigators explain that their findings make it "more feasible to treat acute 
psychoses in a variety of clinical settings rather than (solely) in public men- 
tal hospitals. " 

Patients in the study were young schizophrenics averaging 28 years of 
age, usually suffering either their first psychotic breakdown or first hospital- 
ization, and whom participating clinicians judged to be "markedly ill. " More 
than 400 patients either were given chlorpromazine, two of the newer pheno- 
thiazines (flupheniazine or thioridazine) or served as controls and received 
no drugs. The phenothiazine family of drugs was chosen because it contains 
the tranquilizers with the greatest potency. Chlorpromazine is the oldest 
and most reliable drug of this type. 

Other results of the study were: 

1. Nearly one-half of the improved patients were rated as having 
no symptoms or only borderline illness at the end of 6 weeks. 

2. The degree of improvement had not leveled off by the end of the 
study, indicating that improvement probably was continuing and would 
have been observed if the project had been longer. 

3. Twenty-three percent of patients in the control group showed 
marked or moderate improveinent when no specific drug treatment was 
used. This represents the proportion of patients expected to improve 
with other standard forms of hospital treatment. 

4. All of the three phenothiazines were equally successful and 
showed a strong over -all effect against nearly all schizophrenic symp- 
toms. The variety of symptoms affected by the drugs suggests that they 
have a basic antipsychotic action. They not only helped the hostile over- 
active patient, but also greatly benefited the apathetic, withdrawn patient. 

5. The drugs alleviated the classic schizophrenic symptoms of hal- 
lucinations, thinking or speech disorders, bizarre motor behavior, in- 
appropriate emotion, and helped to improve personal relations. They 
were less effective against feelings of guilt, delusions of grandeur, and 
loss of memory. 

6. Side effects generally were mild despite the higher dosages 
required for patients of this sort. The more common side reactions 
were limited to drowsiness, dizziness, and dry mouth. 

This study has important implications for treatment of mental illness, one 
of the nation's major health problems. About half the patients in United 



Medical News Letter, Vol. 43, No. 7 15 

Stat«s hospitals are psychiatric cases; half of these are schizophrenic. The 
authors conclude, "The findings of this study lend strong support to the rising 
optimism about . . . the treatment of acute schizophrenic psychoses. The 
effects of phenothiazine therapy are not only quantitative . . . they are also 
qualitative in that a wide range of schizophrenic symptoms and behavior are 
favorably altered. " 

The hospitals participating in the study were: Boston State Hospital, 
Boston Mass. ; D. C. General Hospital, Washington, D. C. ; Kentucky State 
Hospital, Danville, Ky. ; Malcolm Bliss Mental Health Center, St. Louis, Mo. ; 
Mercy-Douglass Hospital, Philadelphia, Penna. ; Payne - Whitney Clinic, New 
York City, N.Y. ; Rochester State Hospital, Rochester, N. Y. ; Springfield 
State Hospital, Sykesville, Md. , Institute of Living, Hartford, Conn. The 
data were analyzed by the Biometric Laboratory, George Washington Univers- 
ity, Washington, D. C. , and by the Psychopharmacology Service Center of the 
National Institute of Mental Health. 




RADIATION MEDICINE 



Attention - All AEC-Licensed Maval Hospitals 1 

Atomic Energy Cprnmission Licensing Policies . --A review of Applications for 
Byproduct Material License, Form AEC 313(5/5^),- which have been submitted via 
this Bureau in the past, reveals several repetitive discrepancies. Failure to 
follow procedures set forth in AEC publication: "A Guide for the Preparation 
of Applications for the Medical Use of Radioisotopes," has resulted in unneces- 
sary delay and correspondence between the applicant, this Bureau, and the Com- 
mission. Of especial importance is the matter regarding each application as an 
original. It is the policy of the AEC to require full and complete restatement 
of all conditions on each application, rather than accepting referrals to pre- 
vious licenses and applications. 

While this Bureau attempts to catch any errors and/or omissions on appli- 
cations, returning them to the applicant rather than forwarding them to the 
AEC, the resultant delays only serve to further complicate the situation. 

Further attention of Commanding Officers is invited to the fact that the 
license authorizes Inspection of the facility by the AEC. To emphasize the 
importance of such inspections, and the meticulous and thorough scrutiny made 
of the Installation, the following is extracted from an AEC letter to the 
Cormianding Officer of a naval hospital: 



16 Medical News Letter, Vol. 43, No. 7 

"This refers to the inspection conducted on 196_, of your 

activities authorized under AEC Byproduct Material License Ko. 



It appears that certain of your activities were not conducted in 
full compliance with license conditions and the requirements of the 
AEC's "Standards for Protection Against Radiation," Part 20, Title 10, 
Code of Federal Regulations, in that: 

"1. Contrary to 10 CFR 20.201(b), "Surveys," surveys were 
inadequate to determine: 

a. the quantities and concentrations of radioactive 
materials disposed of by release into the sanitary 
sewerage systemj 

h. the radiation hazards incident to a spill of strontixjm 
90-yttrium 90 in the "Hot" laboratory which reportedly 
occurred during 196_; and 

c. the quantity and airborne concentrations of strontium 
90Tyttri\Mn 90 released from the exhaust hood into un- 
restricted areas as a result of the spill of strontium 
90-yttrium 90 during 196_. 

"2. Contrary to 10 CFR 20.U0l(b), "Records of surveys, 
radiation monitoring and disposal": 

a. records were not maintained showing the materials 
disposed of via the sanitary sewerage system; and 

b. records were not maintained of surveys made pur- 
suant to 10 CFR 20.201(b) in connection with the 
possession and use of strontium 90-yttri\]m 90. 

''3. Contrary to License Condition No. h^, which incor- 
porates your license application dated : 

a. the radiological safety officer did not assess the 
extent of the strontiim 90-yttriTim 90 contamination 
following the spill which reportedly occurred during 
I96_, and did not supervise the decontamination of 
the affected areas as specified in Section VII of 
your "Operating ProeedHre and General Instructions 
for the Radioisotope Laboratory"; and 

b. the radiological safety officer did not inform the 
Radioisotope Committee of the spill of strontium 
90-yttrium 90 referred to above as specified in 
paragraphs 3(f) and 3(g) of NAVHOSP INST. 6^70.2. 

'%. Several sealed sources containing byproduct material had 
not been leak tested at intervals of six months or less 
as required by License Condition Ho. 28(c). Also, records 
of those tests conducted were not maintained in units of 
microcuries as required by License Condition No. 28(d). 

"'JtdB notice is sent to you pursuant to the. provisions of Section 2.201 
of the AEC's "Rules of Practice," Part 2, Title 10, Code of Federal 



Medical News Letter, Vol. 43, No. 7 17 

Regulations, a copy of which is enclosed. Section 2.201 requires you 
to submit to this office, vithin twenty (20) days of your receipt of 
this notice, a written statement or explanation in reply including 
(l) corrective steps which have been taken by you, and the results 
achieved; (2) corrective steps which will be taken; and (3) the date 
when full compliance will be achieved. 

''We understand that your method of evaluating film badges, developed 

at Naval Hospital, involves a comparison of exposed film with film 

standards furnished by the National Naval Medical Center at Bethesda, 
Maryland, Your radiological safety officer reportedly did not know 
whether the film badges and film standards were of the same emulsion 
and whether the same development procedures were employed in developing 
the film badges and film standards. We believe that your film badge 
monitoring program should be reevaluated to establish that there are no 
unnecessary errors being introduced in the evaluation of radiation 
doses received by individuals . We would appreciate clarifying informa- 
tion concerning the adequacy of your film badge monitoring program with 
your reply to this letter. ' 

The foregoing letter and the inspection resulted in a complete reap- 
praisal of this particular hospital's entire radiological safety program. The 
hospital's detailed, two-and-one-half page reply states, in part, ". . .An ex- 
tensive radiation safety program has been instituted and carried out since 
inspection of ______ 1963," an^ goes on, step-by-step, explaining what is now 

being done. A new radiation safety officer has been appointed and the Radio- 
isotope Committee alerted to the requirements of the Code of Federal Regula- 
tions . 

The Bureau of Medicine and Surgery has underwritten the training of a 
number of Medical Corps and Medical Service Corps officers who are capable of 
directing radiation safety programs. If one of these officers is not assigned 
to the staff of the hospital, a request for assistance in designing such a 
program will result in immediate and favorable action, if addressed to Chief, 
Bureau of Medicine and. Surgery, Attn: Code ^k2. 



MISCELLANY 



iOIXO ' 



Notice of Drug Withdrawal 
From: F-D-C Reporte, Washington, D. C. , 26(9): 10, 2 March 1964. 
Text of FDA Statement on Parnate Issued 25 February 1964: 

The Food and Drag Administration has announced that it has concluded that 
the »ew drug tranylcypromine (Parnate) is not safe for continued distribu- 
tion under present labeling, FDA said that a significant number of adverse 
reactions have been reported in patients who were taking the drug alone or 
in combination with other drugs. 

References to increased blood pressure have been found in some 400 
reports on use of the drug from worldwide sources. Reactions range from 



18 Medical News Letter, Vol. 43, No. 7 

high blood pressure and severe headaches to strokes and death. About 50 
cases resulted in cerebral vascular accidents and, in about 15 cases, death 
followed. Six of the reported fatalities were in the United States. The man- 
ufacturer, Smith, Kline & French Laboratories of Philadelphia, estimates 
that three and one -half million patients have received the drug. 

FDA said it has discussed these findings with the connpany and has 
suggested to them that the drug be removed from the market. The Company 
has advised FDA that it does not agree with the Government's conclusions 
and may wish to avail itself of the opportunity for a hearing as provided by 
law. Meanwhile, however, the firm states that it is taking the product off the 
market. FDA said that a notice will be published in the Federal Register 
giving the firm 30 days in which to decide whether it wishes a hearing on 
proposed withdrawal of approval of the new drug application. 

Parnate was first marketed in the United States in March 1961. It is 
a potent prescription drug for the treatment of mental depression. The first 
report of a stroke associated with the drug appeared in the British medical 
journal. The Lancet, in June 1963. Others followed. 

Parnate functions through its effect upon the monoamine oxidase 
enzyme system, one of the enzyme systems which helps to regulate body 
processes, A side effect in many persons being treated with the drug for 
depression is a lowered blood pressure. Paradoxically, however, clinical 
experience shows in some cases a rise in blood pressure associated with the 
administration of the drug. Increases in blood pressure may occur, particu- 
larly when Parnate is administered with certain other drugs, including am- 
phetamines, reserpine, and certain diuretics. 

Smith, Kline & French, in cooperation with FDA, revised the labeling 
of Parnate in October 1963 and issued a drug warning letter to all physicians 
pointing out the new and revised contraindications and warnings. The letter 
warned doctors to discontinue use of the drug when any high blood pressure 
symptoms were observed, not to use it when the patient has a confirmed or 
suspected cerebral vascular defect or disease, and not to use it with other 
monoamine oxidase inhibitors. 



Important Drug Warning s 

Recent reports of adverse reactions associated with the use of Eutonyl 
(pargyline hydrochloride) require that the medical profession be apprised of 
this information. Abbott Laboratories has submitted this information to the 
Food and Drug Administration and has recommended changes in the liter- 
ature for this product. The following report has been prepared by Abbott 
Laboratories in cooperation with the Food and Drug Administration, and 
Abbott particularly wishes to bring to physicians' attention the revised sec- 
tions in their brochure entitled, Contraindications, Warnings and Precautions . 
"Your particular attention is directed toward the danger of induc- 
ing a hypertensive reaction in patients receiving Eutonyl who take a 



Medical News Letter, Vol. 43, No. 7 19 

sympathomimetic drug (amphetamines, ephedrine) or who ingest 
cheese, fermented beer or wine (which contain pressor amine sub- 
stances). Patients should be warned against self -medication, except 
as you (physicians) approve, with any proprietary (over-the-counter) 
drugs, particularly "cold tablets, " "sinus decongestants," or "reduc- 
ing" pills because they often contain amphetamines or other vasocon- 
strictor amines. In the event of a hypertensive reaction, phentola- 
mine*, or a phenothiazine, usually parenterally, may be employed 
to reduce blood pressure. 

We are also reemphasizing the dangers of hypotension which may 
be associated with the use of excessive doses of Eutonyl. It is ex- 
tremely important to avoid severe or prolonged hypotension in patients 
with vascular disease because of the potential risk of thrombosis. As 
previously stated in our literature, caution is necessary with the use 
of certain drugs in patients receiving Eutonyl because an exaggerated 
hypotensive effect may result. Such drugs include antihistamines, 
sedatives and hypnotics, narcotics (notably nneperidine) and of special 
importance, alcoholic beverages. Suggestions have been added for in- 
struction of patients to prevent postural hypotensive episodes. 

Your attention is also directed to the fact that contraindications 
have been added to the literature against the concomitant use of Eutonyl 
with other monoamine oxidase inhibitors and with methyldopa. 

As with extended use of all drugs, a few additional side effects have 
been noted. These have included urinary retention and urgency, and 
rarely, hypoglycemia and skin rash. 

Please report any adverse effects or other unusual experience ' 
observed with the use of Eutonyl to Abbott Laboratories or to the Food 
and Drug Administration. " 

*Regitine (Ciba) 

FROM THE NOTE BOOK 
Meeting of the American College of Physicians 

Medical officers planning to attend the annual meeting of the American Col- 
lege of Physicians at Atlantic City, N. J., 6-10 April 1964, are advised 
that the Armed Forces tri-service social hour will be held under Air Force 
auspices on the evening of Tuesday, 7 April, at the Kents Midtown Restaurant. 
Further details will be available at the meeting. All military officers who 
attend the annual session, their wives and guests are invited to attend. 

The annual dinner meeting of Navy Chiefs of Medicine will be held on 
the evening of Wednesday, 8 April, at the Club in Pomona, N. J,. , (formerly 
the Naval Air Station, Atlantic City). Transportation will be available for 
those who do not have any. 

Medicine Branch, Professional Division, BuMed 



20 



Medical News Letter, Vol. 43, No. 7 



WANTED: ARTICLES FOR TRAINING BULLETIN 



The Naval Training Bulletin describes 
methods and techniques of training through- 
out the Navy, explains plans and programs 
of the Navy Department, describes training 
of other U.S. Government agencies and 
foreign agencies of interest to naval per- 
sonnel, and discusses training develop- 
ments that have application to naval 
personnel. To reflect the training in the 
fleet and at field activities, the Bulletin 
needs articles from readers. Those who 
have participated in the operation of a 
successful training program are in an ex- 
cellent position to pass along their ideas 
and share their experiences. Articles 
from fleet personnel help make the 
Bulletin what it is intended to be; a 
magazine which shows what is actually 
taking place in the fleet, rather than one 
which merely emphasizes pedagogical 
methodology. 

The following types of articles are 
particularly desired: 

• Those describing a training program 
that has solved some unusual problem. 

• Those which describe a new approach 
or reflect new ideas with respect to some 
persistent or recurring problem. 

• Those whose success is reflected in 
the fact that the ship or activity has re- 
ceived some form of commendation. 

• Those simply describing a program 
which has worked well or has shown 
practical results. 



What is needed is practical material, not 
polished prose. The staff of the Bulletin 
will provide any editorial treatment neces- 
sary to make articles conform to accepted 
style and grammar. 

The following is a checklist for articles 
submitted: 

• Does the article deal with something 
with which the author has had first-hand 
experience? 

• Does the article deal primarily with 
facts and ideas which impart informa- 
tion, rather than those which merely 
publicize? 

• Has the article been read and criti- 
cized by others? Have appropriate 
changes been made? 

• Do the main ideas stand out? 

• Have photographs been made to 
accompany the article? Are the photo- 
graphs clear? 

• Is the title short and accurate? 

• Can the main idea of the article be 
expressed in one sentence ? 

This checklist is intended as a guide, not 
a criterion against which articles are judged; 
for example, photographs are desired for 
articles, but they are not essential. Articles 
may be of any length, but articles containing 
between 750 and 3,000 words are jK-eferred. 

If the author wishes his photograph to 
appear with his by-line, he should send a 
photograph of himself (any size is satis- 
factory) with the article. 



From: Naval Training Bulletin, BuPers, NAVPERS 14900 - Winter 1963-1964 



MSC Training Announcement . The attention of all Medical Service Corps 
officers is invited to provisions of BUMED INSTRUCTION 1520. 12B which 
outlines the MSC full-time training program. The next Sanitary Science 
course convenes at the University of California, Berkeley, Calif. , in January 
1965. To be considered for this class, requests must reach BuMed prior to 
1 July 1964. —MSC Division, BuMed 



Medical News Letter, Vol. 43, No. 7 21 



Notice to ACDU and Naval Reserve A. P. A, Psychia trists 

Navy Luncheon to be Held on 6 May 1964 at Meeting of the American Psy- 
chiatric Association . Psychiatrists, active duty and Naval Reserve planning 
to attend the annual meeting of the American Psychiatric Association at the 
Biltmore Hotel, Los Angeles, Calif. ,4-8 May 1964, are advised that the 
annual Navy Luncheon will be held on Wednesday, 6 May, at 12:00 noon in 
Conference Room Two, Biltmore Hotel. Arrangements are being made 
through the Neuropsychiatry Branch, Professional Division, Bureau of Med- 
icine and Surgery. Inquiries may be directed to that office, attention Code 313. 
All U. S. Navy and Naval Reserve or former Naval Reserve psychiatrists and 
neurologists attending the annual meeting are invited to attend. It would be 
appreciated and would also assist in planning if those who expect to attend 
will notify this office in advance of the meeting, 

^ rf i^fi ^ >^ >¥ 

BUPERS REPORT 1080-14 

(Excerpt from ComServPac Information Bulletin, March 1964) 

What Is It ? Enlisted Distribution and Verification Report is a machine pro- 
cessed listing of enlisted personnel attached to a given activity. It reflects 
the actual onboard count as compared with the Bureau established allowance, 
and the TYCOM established Enlisted Distribution Plan "EDP. " 

Who Receives It ? Each ship/unit/ activity in commission. It is distributed 
by cognizant PAMIs to each connmand approximately by the 15th of each 
nnonth. 

What Does It Contain ? Information upon which Distribution Commanders 
effect assignments of individuals. It identifies each individual by name, 
service number, rate and naval enlisted classification code. Additional 
information on the individual's sex, marital status, citizenship, and infor- 
mation concerning the man's duty and VEY status is also provided. 

Who Should See It and Why ? The staff personnel officer should make the 
initial review and verification of the BUPERS 1080-14, ensuring that all 
information is correct for each individual. The Commanding Officer, 
Executive Officer, and Department Heads should examine this report which 
will reveal the rate and rating totals, and the total onboard count for the 
following factors: Enlisted Distribution Plan, Allowance, current onboard 
count, and prospective onboard totals for 1, 2, 3, 4, 5, 6, 7, 8, 9, and 12 months 
in the future. — Hospital Corps Division, BuMed 



22 Medical News Letter, Vol. 43, No. 7 




DEi\IT/IL te ^m^ 11 SECTIOIV 



The Ftinction and Importance 
of Incisal Guidance in Oral Rehabilitation 

Clyde H. Schuyler DDS, Montclair, N.J. J Pros Den 13(6): 1011-1029, 
November-December 1963.* 

An unfavorable incisal guidance may tend to produce abnormal functional move- 
ments of the condyles. It may contribute to abnormal stresses and movements 
which are potentially pathologic. A change or modification of an unfavorable 
incisal guidance will have a favorable influence upon the pattern of movement 
of the condyles. 

There is a degree of resilience and flexibility in the functional move- 
nnents of the condyles, as evidenced by their vertical translation, but there is 
no flexibility or resiliency in the incisal guide factors. The incisal guidance 
is controlled by hard tooth surfaces contacting opposing hard tooth surfaces. 

Anterior teeth which have been in functional contact cannot be taken 
out of contact without creating potentially unfavorable factors. A reasonable 
degree of function is favorable to the retention of teeth, and when the anterior 
teeth are in functional contact at the completion of an oral rehabilitation, their 
relationship remains constant. 

There are many factors which influence the centric maxillomandibular 
relation. Closure on the horizontal hinge axis varies with muscle tone and 
neuropathic influences, with a forward, backward, or a lateral position of the 
head, and position of the body. 

The desirability of a slight freedom of lateral and anterior posterior 
movement in centric occlusion rather than a locked intercuspation in the most 
retruded maxillomandibular relation has been recognized. This freedom of 
movement in centric occlusion promotes patient comfort and reduces the tend- 
ency to bruxism and other traumatogenic influences on the supporting struc- 
tures. 

The author discusses the objectives of an occlusal rehabilitation and 
the importance of recognition of the coordination of the occlusion as one of the 
most important and most connplicated facets of the practice of dentistry. The 
article was written for operative dentistry, however, the principles involved 
are equally important to oral rehabilitation with removable prosthesis and 
should be carefully evaluated by all Prosthodontists. ^(Submitted by CAPT 
M. L. Parker DC USN, NDC, Pearl Harbor, Hawaii) 



Medical News Letter, Vol. 43, No. 7 23 

Incidence and Distribution of Dental Caries 
in the United States 

James M. Dunning, The Dental Clinics of North America, Pgs 291-303, 
July 1962*. 

The article clearly describes the multifactorial nature of dental caries. Among 
the host factors are race, age, and sex. Racial heredity and environmental 
factors are difficult to separate but race does play a part with the Chinese and 
Negroes having least dental caries. In the case of age the greatest intensity of 
the caries process lies in the decade from 15 to 25 years of age. Below the 
age of 30, the difference in the dental caries experience of male and female is 
minor. 

Environmental factors appear more powerful than the personal or host 
factors. There is a marked variation in the United States, with less dental 
caries being found in the South and in regions away from the seacost. Climatic 
and geologic factors can be interpreted as reasons for these geographical vari- 
ations. The areas associated with higher mean annual hours of sunshine, high 
temperature and low relative humidity are associated with low caries. In areas 
where deep-well water is commonly used, natural fluoride in the water has 
been most prominent in producing areas of low caries prevalence. Another 
factor to consider, which is often overlooked, is the total water hardness. The 
shift of population from rural to urban does not appear as a strong factor. 

Besides aiding in estimating needs for dental care in various parts of 
the country these geographical distribution studies in dental disease give cer- 
tain clues to the etiology of dental caries. ^(Submitted by CAPT F. L,. Losee 
DC USN, Ad. Com. Great Lakes. ) 

****** 

Improved Dental Cements 

Technical News, U.S. Department of Commerce, National Bureau of 
Standards, Washington, D. C. 

Promising findings were obtained in recent National Bureau of Standards ex- 
periments with a dental cement (zinc-eugenol) containing the additives o- 
ethoxybenzoic acid (EBA), and fused quartz. It was demonstrated that tliis 
formulation had better strength and quicker setting times than had the cements 
now widely employed, and that it acted as an effective sedative in dental resto- 
rations. These results indicate that the new cement has many dental applica- 
tions, such as; pulp-capping material, sedative intermediate base, and as a 
temporary filling material. 

****** 



24 Medical News Letter, Vol. 43, No. 7 

Fluoride May Be Useful 
in Combating Bone Diseases '^' 

In an abstract of an editorial originally printed in the New England Journal of 
Medicine, it was pointed out that current interest in fluoride for prevention of 
caries in children is expanding to include its possible use in various bone dis- 
eases. 

Studies on effects of high doses of sodium fluoride in treating forms of 
osteoporosis and Paget' s Disease have been favorably reported, according to 
the editorial. The editorial stated: "In all patients so studied, there have been 
no toxic effects. Fluoride seems to be an important bone nutrient; however 
until exact dose response is determined, fluoride treatment must be used with 
caution. 

Early indications of a possible role for the use of fluoride in bone dis- 
eases are favorable. Certainly, the low dose (1 mg per day) currently employed 
in preventing caries in children can be extended to include adults in the hope 
of preventing future osteoporosis. " —Dental Abstracts 9(1): 28, January 1964, 



AMA Po sition on Fluoridation * 

JAMA 186: 64, October 5, 1963. From Dental Abstracts 9(2): 91-92, 
February 1964. 

The official position of the American Medical Association on fluoridation does 
not agree with views expressed by W. C. Black in an editorial, "Dental Caries 
and the Pediatrician, " in the August 1963 issue of the American Journal of the 
Diseases of Children. The AMA does not agree with Dr. Black's statement that 
fluoridation is "unnecessary and unwise, " nor with the four reasons presented 
as evidence. 

Although Dr. Black states that reliance on fluoridated water dosage is 
"highly variable and inaccurate, " the contrary has been demonstrated by years 
of fluoridation in well-controlled studies. Dr. Black presumably would with- 
hold fluoride after the tenth year. Yet, results of recent studies have shown 
that protection is afforded well beyond the age of ten. The implication of harm 
from ingestion of 1 ppm of fluoride after the tenth year is unfounded. 

There is no evidence to support Dr. Black's assertion that fluoridated 
water is of no benefit to plants and may be undesirable for edible plants. 

The American Medical Association's position on the fluoridation of 
public water supplies remains the same as that adopted in 1957 by the House 
of Delegates. Fluoridation should be regarded as a prophylactic measure for 
reducing tooth decay at the community level and is applicable where the water 
supply contains less than the equivalent of 1 ppm of fluorine. 



* The preceding articles were copyrighted by the American Dental Association. 
Reprinted by permission. 



Medical News Letter, Vol. 43, No. 7 



25 



Personnel and Professional Notes 



Dental Officers Selected for Training FY 1965 

The Dental Training Committee convened in the Dental Division, Bureau of 
Medicine and Surgery, on Z7 February 1964, and selected the following dental 
officers for training during Fiscal Year 1965. 

GENERAL POSTGRADUATE COURSE (28) 



CDR Carl J. Swanson 

LCDR Charles K. Phillips, Jr. 

LCDR Ralph P. Huestis 

LCDR Everan C. Woodland, Jr. 

LCDR John H. Hegley 

LCDR Charles G. Evans 

LCDR Thomas L. Whatley 

LCDR Robert A. Vessey 

LCDR James F. Scott 

LCDR John (n) Koutrakos 

LCDR Howard S. Tugwell 

LCDR Ollie V. Hall, Jr. 

LCDR Milton R. Wirthlin, Jr. 

LCDR Barry E» Pines 



LCDR Donald E, Meister 
LCDR Herbert 0. Scharpf 
LCDR Carlton J. McLeod 
LCDR Kenneth E. Brown 
LCDR John E. Williams, Jr. 
LCDR Stanley E. Pepek 
LCDR Albert G. landolo 
LCDR Frederick P. Eichel 
LCDR James T. Christian 
LCDR Malcolm S. Davis 
LCDR Harry E, Semler, Jr. 
LCDR Richard C, Edwards 
LCDR George A. Stanton, Jr. 
LCDR Edward A. Miller 



APPROVED AS ALTERNATES (3) 



LCDR Noel D. Wilkie 
LCDR Robert E, Moore 



LCDR James E. Miller 



ORAL SURGERY TRAINING (9) 



LCDR John D. Cagle 
LCDR William R. Martin 
LCDR Thomas F. McCann 
LCDR Thomas W. McKean 
LCDR James M. Wilson 
CDR James H, Scribner 
LCDR William R. Hiatt 
LCDR John S, Lindsay 
LCDR Bill C. Terry 



First Year Residency 
First Year Residency 
First Year Residency 
First Year Residency 
First Year Residency 
Second Year Residency 
Second Year Residency 
Second Year Residency 
Second Year Residency 



PRQSTHODONTIC TRAINING (6) 



LCDR Ray K, Atkinson 
LCDR Philip R. Falcone 
LCDR Edward F. Klecinic 
LCDR Wallace D. Loo 
LCDR Philip W. Strauss 
LCDR Arthur L. Davy 



First Year Residency 
First Year Residency 
First Year Residency 
First Year Residency 
First Year Residency 
First Year Residency 



26 



Medical News Letter, Vol. 43, No. 7 



PERIODONTIC TRAINING (6) 



CDR George K. Woodworth 
LCDR Ernest T, Witte 
CDR Ernest E, Davies 

LCDR Walter J. Gorman 

LCDR Alexander D, Sanderson 

LCDR George W. Rice, Jr. 



First Year Residency 
First Year Residency 
Civilian Institution 

Long Course- 1 year 
Civilian Institution 

Long Course-1 year 
Civilian Institution 

Long Course-1 year 
Civilian Institution 

Long Course-1 year 



ePERATIVE DENTISTRY (2) 



LCDR Thomas A. Garman 
CDR Julian J. Thomas 



LCDR William K. Bottomley 
LCDR Robert A. Gaston 



Civilian Institution 
Long Course-1 year 

Civilian Institution 
Long Course-1 year 



ORAL MEDICINE (2) 



First Year Residency 
First Year Residency 



ENDODONTIC TRAINING (2) 



CDR Paul E, Zeigler 
LCDR Russell A, Grandich 



First Year Residency 
First Year Residency 



Applications were submitted by several officers for training in Oral Pathology, 
Public Health Dentistry, and Histopathology. The needs of the Dental Corps 
balanced with the limitation of funds determined the priority of subjects and 
the total number of trainees for the fiscal year 1965 program. In light of this, 
selections for advanced training were limited to the subjects listed. Each year 
all specialties are reviewed, and the needs of the Dental Corps determined. The 
action taken by this year's Board has no bearing on future Boards, so those who 
desire are encouraged to re-apply for consideration in future years programs. 

Ticonium Training at Dental Clinic. Washington D.C. CAPT H. H. Fridley, 
Executive Officer of the Naval Dental Clinic, Washington, D.C, has arranged 
a training program in TICON laboratory techniques for personnel of the com- 
mand. Mr. C. F. Mosher, Training Director, Ticonium Division, CMP Indus- 
tries, Albany, New York, will conduct the course during the month of May 
1964. The program will include a demonstration of techniques employed in 
fixed partial dentures utilizing the Ticomatic casting machine. 



:f/: ;^ ^ ^ ^ i^ 



Medical News Letter, Vol. 43, No. 7 27 




PREVENTIVE MEDICIIVE 



Report of Measles Epidemic in the Bonln Islan ds 
June and July, 1963 

Report received by Force MO, ComNavForces Marianas from Dr. D. A. 
Passick, December 1963. 

The epidemic was initiated by a 1 6-year old girl who returned from Guam 
where she was attending school and had been exposed to measles while there. 
Within 14 days, following the appearance of her rash, there were other typical 
cases of measles. An epidemic of about 2-months duration followed. The total 
population at that time was 203. There were 117 cases of measles or 57 per 
cent. 

Human gamma globulin, in modifying doses of 0. 02cc per pound of 
body weight, was administered to 26 individuals including young children and 
one pregnant woman. Of these, 4 had no signs or symptoms of measles, 17 
had mild signs and symptoms, and 5 had typical signs and symptoms. There 
is no accurate information regarding length of exposure at the time of the in- 
jections. 

There were no deaths due to measles. There were no severe compli- 
cations, the only complication being that of a 16-year old girl who exhibited 
bizarre behavior for 2 weeks after having measles. The girl did not have any 
of the signs of meningitis or encephalitis such as fever, headaches, vomiting, 
seizures, or meningeal irritation. Currently, she has no residual problems 
related to the central nervous system. 

Distribution of Cases According to Age Groups 



Age 


Number 


Total Pop. 


Per Gent 


Per Cent 


Group 


Of Cases 


In Age Group 


Of Group 


Of Cases 


0-4 


20 


22 


90.9 


17. 1 


5-9 


25 


29 


86.2 


21.4 


10-14 


35 


36 


97.2 


17. I 


15-19 


25 


26 


96.2 


21.4 . 


20-24 


6 


10 


60.0 


5. 1 


25-29 


2 


6 


33.3 


1.7 


30-34 


1 


10 


10. 


0.8 



28 Medical News Letter, Vol. 43, No. 7 



Age 


Number 


Total 


Pop. 


Per Cent 


Per Cent 


Group 


Of Cases 


In Age Group 


Of Group 


Of Cases 


35-39 


1 


18 




5. 5 


0.8 


40-44 


1 


11 




9. 1 


0.8 


45-49 





8 




0.0 


0.0 


50-54 





3 




0.0 


0.0 


55-59 


1 


6 




16.6 


0.8 


60-64 





4 




0. 


0.0 


65-69 






2 




0.0 
0.0 


0.0 


70-74 


5 




0.0 


75-79 





3 




0.0 


0.0 


80-84 





3 




0.0 


0.0 


85-89 





1 




0.0 


0.0 



There has not been a measles epidemic or even a small outbreak for many 
years (at least 18 years and possibly longer than that) which accounts for the 

very high incidence. 

****** 

Mianeh Fever 

Spectrum, Pfizer Lab. , Pg. 87, November-December 1963. 

Mianeh fever, a clinically distinct type of relapsing fever referred to as the 
Persian form, is an acute infectious disease endemic to the Middle East. It 
is caused by the spirochete Borrelia persica ; and the hematophagous tick 
Ornithodorus tholozani serves both as reservoir and vector. Camels and vari- 
ous rodents commonly harbor the tick. The incubation period averages about 
a week. The initial attack starts abruptly with chills, followed by high fever, 
intense headache, joint and muscle pain, nausea and vomiting, photophobia and 
cough. A characteristic erythematous rash is common during this period. Typi- 
cal rose-colored spots may develop later. Conjunctivitis and iritis are frequent- 
ly seen. Usually, there are four or five febrile episodes following a cyclic pat- 
tern of crisis, remission and relapse. 

****** 
Control of Gonococcal Infections 



With the introduction of penicillin and other antibiotics, it was hoped that gonor- 
rhea would cease to be a public health problem. A World Health Organization 
survey has revealed a significant recrudescence of gonococcal infection in many 
countries. No fewer than 53 of 111 countries and areas in the world have shown 
a persistent increase in incidence since 1957. 



Medical News Letter, Vol. 43, No. 7 29 

In view of the overall failure to control gonorrhea, WHO convened an 
Expert Committee on Gonococcal Infections in 1962, which reviewed in detail 
the many factors relating to the extent, nature, and significance of the problem 
and the reasons why control attempts have been unsuccessful. 

In its report the Committee notes that it is difficult to obtain accurate 
figures on the true extent of gonorrhea throughout the world. Pin-point studies 
have shown the actual number of cases occurring in a given area to be as many 
as 100 times the number reported, and it is estimated that the annual number 
of new cases now exceeds 60-65 million. A large undiagnosed reservoir of 
infection is becoming prevalent in the very young age groups. Complications 
continue to exist. Ophthalmia neonatorum and vulvovaginitis of children, as 
well as serious pelvic inflammation (salpingitis) and sterility in females, con- 
tinue to occur more extensively than is commonly believed to be the case. 

There is no evidence that the wide use of "ideal" antibiotics over the 
last twenty years, particularly penicillin and streptomycin, has in any way 
reduced the reservoir of gonococcal infection. The infectiousness of gonor- 
rhea, its short incubation, the mode of transmission, and other factors have 
not made it possible to evolve epidemiological methods effective against its 
very rapid spread. It has nowhere been possible to bring a sufficiently large 
number of cases and contacts to treatment quickly enough to overtake the rapid 
spread of the infection in the community. Air travel, furthermore, allows ex- 
tremely rapid transfer of infection between countries and continents. There 
also exists itinerant groups at particular risk of infection (migrants, seafarers, 
etc. ). Case-finding and contact treatment, rapid epidemiological procedures 
and culture -testing techniques, preventive treatment, individual and mass 
treatment of special groups or obligatory hospital isolation of infected persons, 
legal notification of contacts, etc, have been of limited value: the methods 
available have been incapable of reversing the epidemiological balance so ad- 
verse to the human host in all regions. The failure to interrupt transmission 
and to control gonococcal infection is world-wide and should be recognized by 
health administrations, the medical profession, and the public. 

Present knowledge of gonorrhea and the techniques available for the 
detection of the gonococcus in the individual, particularly in the female, are 
limited; moreover, these techniques are not widely used. The failure to control 
gonococcal infection by treatment in the mass of patients should encourage 
health administrations to place better central laboratory services at the dis- 
posal of local institutions and doctors in medical and public health practice, 
since etiological agents other than Neisseria gonorrhoeae — such as Bacteriaceae, 
Trichomonas, and viruses— may give rise to similar symptoms to a varying 
degree in different geographical areas. Facilities for specific diagnosis would 
further efforts to control the disease and contribute to a more accurate picture 
of the extent of gonococcal infection. Notwithstanding the limitations of Gram- 
staining (and even more so of methylene blue), these methods are useful as a 
first step for the primary laboratory identification of the gonococcus. The 
sending of smears (for example, by mail) from outlying areas to a central pub- 
lic health laboratory, for primary diagnosis, is not widely practiced. As the 



30 Medical News Letter, Vol. 43, No. 7 

laboratory services develop, inoculation of transport and culture media as well 
as the use of standard techniques, and possibly the introduction of fluorescent 
methods, should pernnit more definitive detection of the gonococcus in clinically 
symptomatic and asymptomatic individuals as well as in epidemiological in- 
vestigations and surveys. In laboratories able to employ inimunofluore scent 
techniques, N. gonorrhoeae can be detected somewhat more rapidly, but not 
more frequently than with the best culture methods. 

There is microbiological evidence in several parts of the world of chang- 
ing sensitivity of circulating strains of N. gonorrhoeae to previously effective 
drugs. In some areas strains "resistant" to penicillin and streptomycin have 
developed and clinical failure rates are higher for dosages and preparations 
effective several years ago. The allergenicity, toxicity, or cost of the drugs 
in use at present also limit their usefulness. 

The methods of health education now used have failed to prevent gonor- 
rhea from spreading among the yoiinger, more exposed, and nnore sexually 
active members of the community, and have not counteracted the development 
of indifference to the seriousness of this health problem among the public in 
general, an indifference which has partly resulted from the ease of treatment 
with effective modern drugs. Moreover, there is already an overall shortage 
of trained personnel to meet the complex epidemiological situation both in de- 
veloped and in developing countries. 

Investigations are therefore urgently needed into new techniques and 
nnethods to improve the scope of the tools already available to applied research, 
whereby new discoveries can be assessed in different geographical, human, and 
microbiological environments, so that they can be used at the point of maximum 
advantage at the earliest moment. The Committee suggested that WHO could 
play an important part in many fields in the promotion and stimulation of pro- 
grams against gonococcal infections. 

The existing treatment policy is geared to continuing research into the 
microbiogenic relationship of host and organism in different parts of the world, 
in order to note and give warning of the degree, the tinne, and, if possible, the 
way in which strains of gonococci becon:ie less sensitive to various drugs. The 
results of such research in one country may provide the basis for prophylaxis 
in another. But new drugs are needed which have few or none of the disad- 
vantages of high cost, side effects, relatively low effectiveness, etc. found in 
some current therapeutic agents. In the laboratory, research is required into 
the improvement and application of existing diagnostic techniques, and the e- 
valuation of new ones lending themselves to uniform interpretation in different 
countries. There is particular need for a serological testing procedure suitable 
for population surveys in developing and developed countries. More suitable 
animals for laboratory research on neisseriae are also required. Finally, the 
ultimate hope for the solution of the many outstanding problems — particularly 
those related to the development of an immunizing agent and skin-testing pro- 
cedures—lies in intensified fiindamental biochemical and immunological re- 
search. 



Medical News Letter, Vol. 43, No. 7 31 

The Committee also emphasized the vinlikelihood of eliminating infec- 
tious diseases by drugs alone, however effective, at least in conditions where 
the incubation period is short, no practical imm\mity is derived from the active 
infection, and no immunizing agent is available. — WHO Chronicle 18(1): 14- 
15, January 1964. 

si; ;{:»!<: ijc :}: :{< 

Time- Temperature Effects on Salmonellae 
and Staphylococci in Foods 

Robert Angelotti, Milton J. Foter, and Keith H. Lewis. Applied Micro- 
biology 9(4): 308-315, July 1961. 

Thermal death time studies were conducted at 5°F intervals from 130° to 150°F 
with strains of salmonellae and enterotoxigenic staphylococci. Heat-resistant 
Salmonella senftenberg strain 775W, Staphyl oc o c c u s aureus strains 196E and 
Ms 149, and non heat-resistant Salmonella manhattan were studied in custard, 
chicken a la king, and Kam salad. 

The Fj4Q values (required minutes of exposure at 140 F to effect 100% 
destruction) were: S. senftenberg 775W in custard 78, in chicken a la king 
81. 5; S. manhattan in custard 19, in chicken a la king 3. 1; S. aureus 196E 
in custard 59, in chicken a la king 47; S. aureus Ms 149 in custard 53, in chick- 
en a la king 40, Survival-kill at all the test temperatures for both salnnonellae 
and staphylococci in ham salad were considerably less than for other foods 
studied. 

D lAQ values (required minutes of exposure at 140OF to effect a 90% 
reduction in numbers) also were calculated from the data. Values for zF and 
z, (slope of the thermal death time and decimal reduction time curves) are 
discussed in relation to type of food, organism, and temperature. 

These data indicate that heating perishable foods of the type studied to 
150°F and holding every particle of the food at this temperature for at least 
12 minutes reduces 10 million or less salmonellae or staphylococci per gram 
to nondetectable levels. This same degree of destruction is achieved in simi- 
larly contaminated foods when held at 140°F for 78 to 83 minutes. 

Based on the calculation procedures employed, it is estimated that 45 
minutes' exposure at 140°F would be necessary to reduce 1, 000 organisms per 
gram to nondetectable levels. 

****** - , ■ ' 

Epidemiology of Salmonellosis 

Philip R. Edwards PhD, Public Health Reports 78(12): 1087-1088, De- 
cember 1963. 

The Salmonella Surveillance Program of the Communicable Disease Center, 
Public Health Service, not only indicates an increased awareness and concern 
regarding salmonellosis, but it is also revealing a greater incidence of the 



32 Medical News Letter, Vol. 43, No. 7 

condition than previously was apparent fron: morbidity and mortality reports. 
As this study is expanded, the reported incidence of salmonellosis will increase 
but it must also be remembered that only a fraction, and probably a small frac- 
tion, of the cases are reported. As of now we have no method of assessing accu- 
rately the actual incidence of the disease. 

Today, the great majority of reported incidents of salmonellosis are 
classified as sporadic cases. Yet it seems unlikely that many cases of salmo- 
nellosis are truly sporadic and not connected with other occurrences. Lack of 
demonstrated relations in such cases can be attributed only to the difficulties 
encountered in establishing causative connections between them. Among these 
difficulties may be the lapse of time in establishing etiological identity of cases, 
lack of rapid collection of data on etiologically identical cases, the niultiple 
pathways of infection to be investigated, and the lack of a sufficient number of 
properly trained personnel to londertake the intensive investigations required. 
National and international reporting of salnnonellosis on a current basis, as 
described by Sanders and Newell, should solve some of these difficulties, and 
it is hoped that interest generated by such progranns eventually will aid in the 
solution of others. 

The occurrence of salmonellae in poultry and other aninnals, in animal 
feeds, and in foods for human consumption and the incidence and epidemiology 
of salmonellosis in man were discussed, but some facets of these discussions 
should be emphasized. The changing food habits of man and animals must be 
considered. Both nnan and his domestic livestock now consume foods which are 
mass produced and which frequently contain multiple ingredients prepared by 
a variety of subsidiary suppliers. This situation has resulted in a greater de- 
gree of contamination of food products with salnnonellae than existed when foods 
and feeds were prepared in the individual kitchen and on the individual farm. 
This fact is amply confirmed by many reports in the literature. Galton, in 
particular, has spoken of increased incidence of salmonellosis in herbivorous 
animals and our experience supports this conclusion. This incidence seems to 
directly connected with the presence of the bacteria in feeds, since salmonellae 
of identical serotype and phage type have been found in infected animals and in 
the feeds they consumed. 

The role of the human carrier, which has not been stressed in this dis- 
cussion, should not be ignored. The isolation of such organisms as shigellae, 
S. typhi and S. paratyphi A from foods illustrates this role. Some years ago, 
Felsenfeld and Young in reviewing the literature found that Z6 of 56 outbreaks 
of salmonellosis caused by nonhost-adapted serotypes were traced to human 
carriers. As McCroan mentioned, one must be careful to distinguish between 
culprits and victims in reviewing the carrier status of food handlers. Yet there 
would seem to be little doubt that the presence of salmonellae in the foods and 
carcasses with which the food handler is in continuous contact predisposes to 
the carrier state. Among this class of employees the repeated ingestion of 
small numbers of the bacteria nnay lead to the production of asynnptomatic 

temporary carriers. Further, the particular vehicle by which salmonellae 
gain entrance to an area of food preparation probably is of secondary impor- 
tance. 



Medical News Letter, Vol. 43, No. 7 33 

In the past the discrepancies in the reported percentile distribution of 
serotypes in man, animals, and egg products on the one hand and in foods and 
food ingredients on the other have been perplexing and disturbing. S. typhimurium 
is by far the predominant serotype in man, animals, and egg products, but it 
constitutes only a small percentage of the serotypes isolated from foods and 
feeds. Recently, the author was informed by Dr. E. Kampelmacher, National 
Institute of Health, Utrecht, the Netherlands, that if a sufficient number of sam- 
ples of each lot of feed is examined, S. typhimurium can be found in a high per- 
centage of the lots examined. Further, it must be admitted that little is known 
regarding the comparative invasiveness of the individual serotypes, as such, ver- 
sus ability of individual strains of each serotype to produce disease. Such con- 
siderations must be taken into account in connparing the distribution of sero- 
types in foods and in clinical cases. 

It is most encouraging that industry itself is taking a serious view of, 
and an active interest in, the presence of salmonellae in food and food ingredi- 
ents. The efforts of Dr. G. M. Dack of the Institute of Food Research and of 
Dr. C. F. Niven, Jr. , of the American Meat Institute Foundation have assisted 
materially in delineating the problems faced by the food industries of this coun- 
try. They have investigated the presence of salmonellae in human foods and 
animal feeds and studied various sources and mechanisms of contamination. 
While the industries concerned are by no means insensitive to the public health 
aspects of salmonellae in food and food products and are motivated by the desire 
to market a wholesome product, it must also be admitted that the problem is 
not devoid of economic aspects. 

When a large food processor insists that the ingredients which he pur- 
chases be free of salmonellae, a powerful incentive is provided the subsidiary 
supplier to produce an acceptable product. Requirements of this sort undoubted- 
ly will be more generally adopted as the widespread distribution of salmonellae 
is more fully publicized and better understood. Further, there is continually 
more pressure brought upon the purveyor of livestock to supply animals that 
are thrifty and have a high livability. In many instances, flocks known to be 
infected are excluded as breeding stock. 

Thus, one may adopt a rather optimistic outlook for future solution of 
many present problems. The ecology and control of the organisms are being 
studied more closely, and methods are gradually being devised to free food 
ingredients of salmonellae and to prevent contamination of the finar products. 
These efforts, combined with those of the sanitarian and the epidemiologist, 
may be expected to have a salutary effect. However, it is essential to maintain 
and stimulate the interest which has been aroused among workers in medicine, 
public health, industry, and agriculture. This can be done only through continued 
investigation of the many -aspects of salmonellosis and dissemination of the 
knowledge thus gained in such a manner that it is brought to the attention of all 
concerned. 

3^ 4e :)c ^ ^^ :^ 



34 Medical News Letter, Vol. 43, No. 7 



Mnxxia 




Did you know: 

That it is anticipated that the WHO Filariasis Research Unit in Rangoon, 
established in October 1962 in collaboration with the Government of Burma, may 
one day become a filariasis research center for the whole of the South-East Asia 
Region and parts of the Western Pacific Region, providing consultant services 
to national health administrations, and training workers from the different coun- 
tries concerned? (1) 



That the first Expert Committee on the Control of Enteric Diseases to 
be convened by WHO met in Geneva from 12 to 18 November 1963, to review 
the numerous activities of WHO and of Member States in this field and to put 
forward recommendations for effective control measures against these diseases? 

WHO has been engaged for nnany years on the study of enteric diseases. 
From 1953 to the present time, a comprehensive investigation of the effective- 
ness of enteric vaccines has been carried out. Field trials in Yugoslavia, USSR, 
British Guiana and Poland have covered more than 1 million people, and labo- 
ratory studies have been carried out in 20 laboratories throughout the world. 
The results of these studies show that certain enteric vaccines are highly ef- 
fective in the control of typhoid fever, although the effectiveness of the para- 
typhoid component of the vaccines needs further study. International reference 
preparations of typhoid vaccines have been established recently by the WHO 
Expert Committee on Biological Standardization, and laboratory potency testa 
more reliable than those used in the past have been developed. (2) 



That the Republic of Mongolia became a Member of the World Health 
Organization in 1963, and that the Organization is the first specialized agency 
of the United Nations to undertake a program of assistance in that country? 

According to the plan of operations signed by the Government and WHO, 
the WHO team will work with the Ministry of Health in planning and carrying 
out a 5-year program of research into prevalent communicable diseases, such 
as gastrointestinal infections and zoonoses. Assistance by WHO in tuberculosis 
control and the organization of laboratory services will also be given, and 
fellowships will be granted to Mongolian health workers for studies abroad. (3) 



Medical News Letter, Vol. 43, No. 7 35 

That the estimated distribution of oral poliomyelitis vaccine sine 1954 
had reached cumulative totals, as of October 1963, of 454, 557, 000 doses of 
inactivated vaccine, 79, 634, 000 doses of Type I oral vaccine, 66, 436, 000 doses 
of Type II, and 66, 771, 000 doses of Type III? (4) 



That a 5-year study to determine what happens to pesticides after com- 
pleting their tasks of killing insects is being undertaken at Rutgers University, 
New Brunswick, N. J. ? A grant of nearly $200, 000 has been made by the Public 
Health Service to finance the first year. 

Among the questions the scientists will attempt to answer is whether a 
pesticide, such as DDT, is decomposed in the soil, leaches out of the soil into 
streams, or is taken up by weeds and food plants. Entitled "The Fate of Pesti- 
cides, " the study will include how pesticides are retained or released in vari- 
ous types of clays and other soils, the interactions between pesticides and soil 
microorganisms, behavior in water, retention by fish, absorption and accumu- 
lation in plants and the possible forination of tumors or other cellular changes 
in animals. (5) 

Bibliography: 

1,2,3. WHO Chronicle 17(12}, December 1963. 

4. PHS Morbidity and Mortality Weekly Report 36(6): 31, February 5, 
1964. 

5. This Week in Public Health, Mass Dept Pub Hlth 13(8): 72, February 
24, 1964. 

sk sff nC sft sk ^ 

Research Projects Completed by 
U, S. Navy Preventive Medicine Unit No. 2 

The following research projects were completed by U. S. Navy Preventive 
Medicine Unit No. 2 during 1963: 

1. Field Evaluation of the RPR Card Test for Syphilis, 
Report No. 3960-LB-23, May 1963. 

2. Evaluation of the Modified RPR Card Test for Syphilis, 
Report No. 3960-LB-24, Jime 1963. 

3. Survival of Microorganisms in Stuart's Transport Media, 
Report No. M8-LB-26, June 1963. 

4. Special Testing of Polyurethane Foam Rubber Mattresses, 
(Bacteriological), Report No. 3960-L,B-32, Sept. 1963. 

5. Special Testing of Neoprene Foam Rubber Mattress, 
(Bacteriological), Report No. 3960-LB-33, Dec. 1963. 

:}: :J: sis >}! sj: ;}: 



36 Medical News Letter, Vol. 43, No. 7 

Malaria Eradication in I96Z 

WHO Chronicle 17(9): 335-350, September 1963. 

The greatest advance in the malaria eradication program in 1962 was a large 
increase in the area transferred to the consolidation phase, the population of 
which rose to Z43 million in 1962. This is the area where transmission of ma- 
laria has ceased long enough for the reservoir of infection in the population to 
reach such a low level that spraying operations can safely be stopped and re- 
placed by surveillance. Out of a total population of 1, 472 million in the origi- 
nally malarious areas, there were 572 million people in areas that had reached 
the consolidation and maintenance phases in 1962, an increase of 44%over the 
number recorded in 1961. The greatest increase occurred in South-East Asia. 
Of the world previously endangered by malaria, 72% of the population receives 
the benefits of the malaria eradication program. Figure 1 (pg. 37) gives the 
epidemiological assessment of malaria in the world on 31 December 1962. 

A Survey of the Regions. Africa. The only eradication programs in the Afri- 
can Region are on the islands of Mauritius and Zanzibar, and in Swaziland and 
the Republic of South Africa. Following the acceptance of a policy of pre- 
eradication programs in the less developed countries, the Regional Office for 
Africa in 1962 was engaged, at the request of the Governments concerned, in 
converting malaria eradication pilot projects into pre -eradication programs 
in Cameroon, Ghana, Mozambique, Northern Nigeria, Togo, and Uganda, and 
initiating new pre-eradication programs in Liberia, Madagascar, Mauritania, 
Nigeria (2), and Senegal. 

The Americas. During the year, the attack phase was completed throughout 
British Honduras, Jamaica, Trinidad, and Tobago, and these areas entered 
the consolidation phase. In parts of Argentina, Bolivia, Colombia, Costa Rica, 
Guadeloupe, Guatamala, Honduras, Nicaragua, and the Panama Canal Zone, 
Peru, Surinam, and Venezuela, further areas were placed in the consolidation 
phase. Out of a total population of 153,891, 000 in the originally malarious areas, 
49, 386, 000 are in the attack phase and 13, 753, 000 in the preparatory phase. 
However, progress was not uniform throughout the Region. Administrative and 
financial deficiencies were responsible for setbacks in some areas. 

South-East Asia. With the exception of Burma and Thailand, there has been 
an overall improvement in malaria eradication programs in the South-East 
Asian Region. Ceylon, which has the most advanced malaria eradication pro- 
gram in South-East Asia, recorded 31 malaria cases during the year and only 
2 between July and Decembei;, both of which had come from the Maldive Islands. 
The national malaria eradication program of India entered its 5th year 
of operation in 1962. Altogether 390 units, each covering over a million people, 
were in operation. In the 140 linits, covering 153 million population, from which 
spraying was withdrawn during the year, only 1,632 positive slides were found 
during surveillance up to the end of September and not a single case was re- 
corded from 56 out of 140 units in the consolidation phase. Early in 1963 an 
additional area, with a population of approximately 90 million, passed into the 
consolidation phase. 



TABLE 1. MALARIA ERADICATtOI* BY REGION ON 31 DECEMBER 1BS2 





Population in thousands 




Total 


Areas where 
malaria was 
newer Indige- 
nous or 
disappeared 
without 
specific 
antlmalaria 
measure* 


Areas 
originally 
maiarlou* 


Area* where 

malaria 

eradication 

claimed 

phase) 


Areas where eradication programmes are in prograa* 




Region 


Consolida- 
tion phase 


Attack 
phase 


Preparatory 

phase 


Total 


Areas whara 

eradication 

programme 

not yet 

started 


Africa 


17! 434 


14 815 


157618 


3£78 


1435 


1155 


- 


2590 


151751 


The Americas 


429726 


275835 


153 891 


B9S26 


30436 


40386 


13783 


nS76 


900 


South-East Asia 


634178 


35 238 


599440 


1467 


162 028 


381060 


9191 


552279 


45694 


Europe 


606861 


301937 


306024 


2«744 


30026 


12 987 


- 


43013 


18 167 


Eastern Mediterranean 


212546 


36419 


176127 


1884 


14488 


12705 


10077 


37268 


136 975 


Western Psclfic 
(excluding Mainland 

China, North Korea, and 

North VIet-Nam) 


816873 


137120 


78 453 


17367 


4766 


3809 


280 


8855 


52231 


Total 


2 363 818 
(3058 830)* 


891364 


1472 454 


329 066 


243177 


461102 


33301 


737580 


405806 



a 
n 

Eu 

a 
m 

a 

rt 

(t 
H 

o 






2! 
o 



* The figure In parentheses Includes the estimated population (of 695112 thousand) of China (mainland). North Korea, and North VIet-Nam from which no other 
Information Is avallaiale. 



-4 



38 Medical News Letter, Vol. 43, No. 7 

The program in Indonesia showed a marked improvement. This pro- 
gram was assessed by a special evaluation team sent by WHO and the U. S. 
Agency for International Development (AID) during the last quarter of 1962. 
The assessment report stressed the operational efficiency of the program, but 
noted some failure to undertake systematic investigation and follow-up of posi- 
tive cases. 

Europe. Albania, Bulgaria, Greece, Portugal, Romania, Spain, the USSR, 
and Yugoslavia achieved objectives. The last zones in the attack phase still 
existing in those countries moved into the consolidation phase at the end of 
196Z. The eradication program is less advanced in Turkey, Algeria, and Mo- 
rocco. 

Eastern Mediterranean . Among the 25 countries or territories in the Eastern 
Mediterranean Region, 6ne — Kuwait— is naturally free from malaria; four- 
Aden Colony, Cyprus, French Somaliland, and the Gaza Strip— have reached 
the maintenance phase and after satisfactory assessment of the situation, will 
be eligible for certification that malaria has been eradicated. Agreement was 
reached with the Government of Cyprus for such an assessment in 1963. 

One-third of the total population of Israel is in areas that have reached 
the maintenance phase; the remaining territories are well advanced in the con- 
solidation phase. The program in Iraq is at an advanced state. During the year, 
90. 5% of the total population in risk areas were in the consolidation phase. In 
Jordan, the areas under consolidation were expanded to cover almost 94% of 
the total population at risk. In Syria, territory covering 4/5 of the total popu- 
lation at risk is now in the consolidation phase. 

The Pakistan program, in its second operational year, proceeded 
according to schedule. The attack operations were extended to protect a popu- 
lation of 4, 400, 000. The preparatory phase activities cove red another 8, 338, 000 
in the 2 parts of the country. 

Western Pacific . About 1/3 of the 78 million people in the originally ma- 
la ri'ous~areas~of"the Western Pacific Region (excluding Mainland China, North 
Korea, and North Viet-Nam) are now covered by eradication programs. 

China (Taiwan), North Borneo, Sarawak, the Ryukyu Islands, and the 
Philippines, have full eradication programs. In the Federation of Malaya and 
the British Solomon Islands Protectorate, malaria eradication pilot projects 
are in operation. 

Training of National Malaria Eradication Staff. Wherever possible, and par- 
ticularly with non-professional staff, every effort is made to arrange that the 
various categories of personnel are trained in their own countries. Training 
outside the countries concerned may be necessary and desirable for limited 
numbers of staff at the professional level and staff in more responsible posi- 
tions in large programs. Training courses at the established international 
training centers at Belgrade (Yugoslavia), Cairo (United Arab Republic), Sao 
Paulo (Brazil), Kingston (Jamaica), and Maracay (Venezuela) have continued. 

(to be continued) 

:{: :j( 3>; ^ »|c 9ic 



Medical News Letter, Vol. 43, No. 7 39 




RESERVE ^m^^ SECTiOlM 



ATTENTION: Reserve Nurse Corps Officers 
on inactive duty 

This is an excellent time for you to return to active duty if you are qualified 
and interested. We have vacancies due to normal attrition and increasing 
numbers for voluntary retirements. If you hold the rank of Lieutenant Junior 
Grade or Lieutenant and could complete 20 years of active duty before reach- 
ing age 55, you may apply. Application for recall to active duty NavPers 2929 
may be obtained at the nearest naval recruiting station. 

:{g :^ ^ ^ jj: :^ 

Reservists Eligible 

For Tax Deductions 

(continued) 

Transportation, Travel Expenses 

All travel and transportation allowances paid by the Navy Department 
when you are in a mileage or per diem status are considered to have been ac- 
counted for to your employer. 

If you broke even— or if you do not choose to deduct excess expenses- 
you may simply answer "yes" to the questions relating to expense accounts on 
page 2, Form 1040, or check item 8, page 1, Form 1040A, and forget the 
matter. On the other hand, if allowances exceeded expenses, you should answer 
"yes" to the questions on page 2 of Form 1040, and enter the excess — labeled 
"excess reimbursements"— as "wages. " 

If you claim excess expenses— or if no allowances were authorized- 
all allowances, reimbursements and expenses must be listed. The excess ex- 
penses must be listed. The excess expenses are computed on IRS Form 2106 
and deducted from your Navy pay, if any, before entering your net wages or 
expenses as "wages" on page 1 of Form 1040. 

"Travel expenses" include meals and lodging of Reservists, who, 
under competent orders and with or without compensation, are required to 
remain away from their principal place of business overnight in the perform- 
ance of authorized drills and training duty. 

Reservists required to work and drill on the same day at each of two 
different locations within the same city or general area may deduct one-way 
"transportation expenses" in going from one place of business to another. When 



40 



Medical News Letter, Vol. 43, No. 7 



they return home before drills, one-way expenses from home to place of drill, 
not to exceed expenses from place of work to place of drill, may be deducted. 

Round-trip transportation expenses are deductible when the duty area 
is situated beyond the city or general area which constitutes the principal place 
of business, provided free transportation between these locations is not furnished 

by the Navy. 

Expenses of an automobile would ordinarily include such items as 
gasoline, oil, minor repairs, depreciation, and the like. If you keep a record 
of all automobile expenses for the year, you can easily determine the amoimt 
of deduction for your drill trips. One way to do this is to take the ratio of the 
total mileage of your drill trips to the total mileage for the year, and apply 
that percentage of your total expenses for the year. 

You can find additional information on income tax deductions in the 
pamphlet, Federal Income Tax Information for Service Personnel , prepared 
annually by the Judge Advocate General. Copies of this publication should be 
available at your Naval Reserve training center or the nearest naval activity. 

— The Naval Reservist, March 1964. 

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